Provider Demographics
NPI:1700087244
Name:GONZALEZ, LAUREN MAVIS (MA, SLP)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MAVIS
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1406
Mailing Address - Country:US
Mailing Address - Phone:631-438-9535
Mailing Address - Fax:
Practice Address - Street 1:28 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1406
Practice Address - Country:US
Practice Address - Phone:631-438-9535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016207235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist